Effects of hand preference on learning episiotomy skills: a study conducted with midwifery students

Abstract

Background

Current educational materials and clinical practice protocols are largely designed for right-handed students or workers, which leads to additional challenges for left-handed midwifery students in learning how to perform episiotomies, which require fine motor skills. Adapting educational environments and content to students’ handedness is a necessity to help students gain skills and to ensure patient safety.

Objective

This study was conducted to compare the levels of challenges experienced by 3rd - and 4th -year midwifery students in Turkey during episiotomy and episiotomy repair procedures according to their handedness (right, left, ambidextrous), and to investigate the relationship between hand dominance intensity measured by the Edinburgh Handedness Inventory and the reported difficulty level.

Method

The study sample consisted of 769 third- and fourth-year midwifery students at universities in Turkey during the 2022–2023 academic year. Data were collected using the Student Information Form and the Edinburgh Handedness Inventory. Data were analyzed using descriptive statistics, Fisher’s Exact Test, and binary logistic regression analysis.

Results

Of the participating students, 82.4% were right-handed, 7% were left-handed, and 10.6% were ambidextrous. The left-handed students had greater difficulty in performing episiotomy and repair procedures than did the right-handed and ambidextrous students both in the laboratory and in the clinical settings (p < .05). Binary logistic regression analysis identified difficulty experienced during clinical episiotomy practice and laboratory-based episiotomy repair training as significant predictors of left-hand use (p < .05).

Conclusion

The results of the study clearly demonstrated that the left-handed students needed additional support to acquire psychomotor skills. Therefore, left-handed practice should be regularly supported in episiotomy training through physical conditions, equipment, and supportive mentoring programs, which will not only improve left-handed students’ technical competence and confidence, but also maximize patient safety.

Clinical trial number

Not applicable.

Introduction

Handedness is a fundamental concept that determines which hand individuals use more effectively when they perform various functions in daily life. While individuals who prefer their right hand for activities such as writing, painting, and using cutlery are defined as “right-handed,” those who use their left hand are defined as “left-handed,” and those who can use both hands equally are called “ambidextrous” [1]. As indicated in several studies, handedness varies from country to country and from region to region. While the right-handedness rate in society is approximately 90%, the remaining 10% are left-handed or ambidextrous individuals [2–4].

Since most tools and equipment used in daily life are generally designed for the use of right-handed individuals, left-handed individuals have difficulty in adapting to these systems, which negatively affects their performance, particularly due to the ergonomic design of equipment used in surgical training and practice [5–7].

Episiotomy is a surgical intervention performed during labor to protect the perineum, prevent lacerations, and to ensure the safe, rapid, and successful delivery of the fetal head [8–10]. Episiotomy, which was preferred for difficult births in the past, has become almost routine today due to technological advances, widespread use of antibiotics and anesthesia, and efforts to prevent potential trauma (e.g., anal sphincter injuries) likely to occur in maternal and fetal tissues, and to minimize associated malpractice risks [11–13]. Episiotomy rates vary significantly from one country to another: nearly 100% in Taiwan, 62.1% in Nigeria, 40.6% in Italy, 27% in Hong Kong, and 24.5% in the United States [8, 14, 15]. In Turkey, its application rate is 90% in primiparous women and 52% in all births [16–18].

The International Confederation of Midwives (ICM) recommends that a balanced mix of theoretical and practical training should be provided to prospective midwives during their training to gain them skills to achieve their profession competently. Within this context, the ability to perform an episiotomy is a fundamental skill in midwifery education [19, 20]. Efforts are underway to reduce the high rate of episiotomies, both by placing emphasis on the importance of this topic in midwifery education and through initiatives by the Ministry of Health. However, given these rates, midwifery students not only must learn how to manage normal labor but also must be able how to perform critical interventions such as performing and repairing episiotomies skillfully before they graduate.

Episiotomy is among the psychomotor clinical skills requiring technical competence [21]. According to Fitts and Posner’s Skill Acquisition Model, psychomotor skills develop within a learning process consisting of cognitive, associative, and autonomous stages. During this process, individual differences can affect students’ learning experiences and skill acquisition in technical clinical applications [22]. However, the widespread adoption of a right-handed perspective in education aggravates the challenges faced by left-handed students and can create obstacles for left-handed midwives to develop their professional competencies [23–25].

Therefore, in midwifery education, individual differences should be taken into account, and supportive approaches should be adopted more, and educational models should be implemented to help midwifery students develop their hand and professional skills.

In the literature, there is a gap regarding studies in which the difficulties experienced by midwifery students due to handedness while they perform episiotomy and repair episiotomy are addressed. Understanding the impact of handedness on learning will ensure the restructuring of educational programs aimed at meeting the individual needs of students. Therefore, the present study was aimed at investigating the relationship between the handedness of third- and fourth-year midwifery students in Turkey, their dominant hand use as determined by the Edinburgh Hand Preference Inventory (EHPI), and their difficulty in performing episiotomy and repairing episiotomy.

Materials and methods

Type of the study

The study is a cross-sectional study.

Population and sample of the study

The study population consisted of 7228 third- and fourth-year midwifery students studying at state and foundation universities offering midwifery education in Turkey during the 2022–2023 academic year. The reason for including the 3rd and 4th grade students is that episiotomy training is given in the third year, and students conduct laboratory and clinical practices in their third and fourth years. In Turkey, episiotomy training in midwifery programs begins with theoretical courses, followed by preclinical laboratory training using simulation models or various practice materials such as sponge, chicken breast, or beef tongue, etc. depending on the laboratory infrastructure of the university. Then, students practice episiotomy incision and repair procedures in clinical settings under the supervision of instructors or clinical consultants. Because, the present study was conducted in midwifery departments in different regions of Turkey, no standard educational intervention was applied before the study. Therefore, challenges faced by the participants during these procedures were assessed based on their self-reported experiences within their educational processes.

The YOK ATLAS website, the official database of the Council of Higher Education that provides information about how universities and departments accept students and the number of students to be accepted in departments in Turkey, was used to determine the population size [26]. Sample selection was made to ensure generalizability of the research results to the study population and the sample’s representativeness of the study population. The sample size was calculated as a minimum of 365 people at a 5% margin of error, a 50% incidence rate, and a 95% confidence interval. However, considering the possibility of withdrawals and/or losses during the study, it was decided to include more students in the sample. Therefore, 769 students who agreed to participate in the study and filled out the forms completely were included in the study sample.

Data collection tools

Research data was collected via Google Forms using the “Student Information Form” and the “Edinburgh Handedness Inventory.” In the forms, questions about the participants’ sociodemographic characteristics, hand preferences, and self-reports regarding the difficulties they experienced during episiotomy procedures were included. The concept of “hand dominance-related difficulty” used in the present study refers to students’ self-reported perceptions of the difficulties they experience regarding the use of their dominant hand during episiotomy procedures.

Student information form

The form consists of seven items questioning respondents’ characteristics related to their year at school, income status, and active hand use, etc. and 18 items questioning the way through which they perform episiotomy procedures, difficulty they perceive due to hand use during episiotomy and episiotomy repair procedures in laboratory and clinical settings, the number of procedures performed, individual practice attempts to improve skills, and support provided by instructors for left-hand use during laboratory and clinical practices.

Edinburgh handedness inventory (EHPI)

EHPI was developed by Oldfield (1971) to assess respondents’ hand use in daily living activities [27]. The inventory consists of 10 items evaluating hand use during common motor tasks, including writing, drawing, throwing, using scissors, brushing teeth, using a knife, using a spoon, sweeping with a broom, striking a match, and opening a box lid. The Turkish adaptation and reliability study of the questionnaire was conducted by Uysal et al. (2019) [1]. Participants’ responses are rated according to the Geschwind Scoring, resulting in a score ranging from − 100 to 100. Of the respondents, those whose score is > 40 are right-handed; those whose score is between − 40 and + 40 are ambidextrous, and those whose score is <-40 are left-handed. In the original study, the reliability of the Edinburgh Handedness Inventory was assessed through item relations and laterality score distributions [27]. In several studies in which the EHPI was adapted into different languages, it has been reported that it has a high level of reliability. The Cronbach’s alpha coefficient was calculated as 0.877 in the Portuguese version, 0.877 in the Chinese version [28, 29], and as 0.936 in the present, indicating that the scale has a high level of internal consistency in the sample group. In the Turkish validity and reliability study of the EHPI, test-retest analyses revealed that Cohen Kappa coefficients were excellent for most of the activities, and good only for the tooth brushing activity.

Data analysis

The SPSS (Statistical Package for Social Sciences) version 25.0 was used in the statistical analysis of the study data. In the analysis of the data, descriptive statistical methods (minimum and maximum values, arithmetic mean, standard deviation) and Fisher’s Exact Test were used. A p-value of less than 0.05 was considered statistically significant.

Results

Of the midwifery students who participated in the study, 46.9% were third-year students, 53.1% were fourth-year students, 75.9% preferred midwifery of their free will, 88.6% were right handed, 8.3% were left handed, and 3.1% were ambidextrous (Table 1).

Table 1.

Descriptive characteristics of students

Variables	Number	%
Year at School
3	361	46.9
4	408	53.1
Did You Prefer the Midwifery of Your Free Will?
Yes	584	75.9
No	185	24.1
Which Hand of Yours Do You Actively Use?
Right hand	681	88.6
Left hand	64	8.3
Both hands	24	3.1
Total	769	100

According to the results of the EHPI, of the participating students, 82.4% were right-handed, 7.0% were left-handed, and 10.6% were ambidextrous (Table 2).

Table 2.

Handedness of the participants according to the EHPI

handedness	Number	%
Right handed (Inventory Result: > +40)	634	82.4
Left handed (Inventory Result: < -40)	54	7.0
Ambidextrous (Inventory Result: between − 40 and < + 40)	81	10.6
Total	769	100

Of the students who participated in the present study, 67.4% performed episiotomy during laboratory practices and 89.6% of these students stated that they did not have any difficulty due to the use of their dominant hand. During clinical practices, only 17.9% of the students performed episiotomy and 77.5% stated that they did not have any difficulty due to the use of their dominant hand. During laboratory practices, 591 out of 769 students performed episiotomy repair. Of these students, 89.0% did not have any difficulty performing episiotomy repair. In the clinical setting, 43.3% of the students performed episiotomy repair. Of the students who repaired episiotomies in the clinical setting, 80.8% did not have any difficulty performing episiotomy repair due to the use of their dominant hand. While 87.7% of the students performed the episiotomy procedure with their right hand, 84.7% performed the suturing procedure more comfortably with their right hand. Students who made individual attempts to develop their skills for performing episiotomy and episiotomy repair used sponges most. Of the students who actively used their left hand, 62.5% and 68.8% were not encouraged by their educators during laboratory and clinical practices, respectively (Table 3).

Table 3.

Participating students’ episiotomy practices-related characteristics

Variables	Number	%
Do you perform episiotomy during laboratory practices?
Yes	518	67.4
No	251	32.6
Do you have difficulty in performing episiotomy during episiotomy training due to the hand you use? (n: 518)
Yes	54	10.4
No	464	89.6
Do you perform episiotomy during clinical practices?
Yes	138	17.9
No	631	82.1
Do you have difficulty in performing episiotomy during clinical practices due to the hand you use? (n:138)
Yes	31	22.5
No	107	77.5
Do you perform episiotomy repair during laboratory practice?
Yes	591	76.9
No	178	23.1
Do you have difficulty performing episiotomy repair during training due to the hand you use? (n: 591)
Yes	65	11.0
No	526	89.0
Do you perform episiotomy repair during clinical practices?
Yes	333	43.3
No	436	56.7
Do you have difficulty performing episiotomy repair in clinical practices due to the hand you use? (n: 333)
Yes	64	19.2
No	269	80.8
Which hand of yours do you use more comfortably while performing episiotomy during laboratory and clinical practices? (n: 560)
Right hand Left hand Both hands	491 51 18	87.7 9.1 3.2
Which hand of yours do you use more comfortably while performing episiotomy repair during laboratory and clinical practices? (n: 652)
Right hand Left hand Both hands	552 64 36	84.7 9.8 5.5
What material do you use to improve your episiotomy and repair skills? (n: 125)
Sponge Chicken Sponge/Fabric Soft silicone episiotomy set Video viewing Orange peel Beef tongue	47 24 24 10 9 7 3	38.4 19.2 19.2 8.0 7.2 5.6 2.4
Are left-handed students encouraged to use their left hands actively during laboratory practices by the educator? (n: 64)
Yes No	24 40	37.5 62.5
Are left-handed students encouraged to use their left hands actively during clinical practices by the educator? (n: 64)
Yes No	20 44	31.3 68.8

As can be seen in Table 4, the left-handed participants experienced more difficulties during episiotomy and episiotomy repair in both laboratory and clinical applications than did the right-handed participants. This difference was statistically significant in all application areas (p < .001). These results suggest that hand dominance may affect students’ psychomotor adaptation processes in both laboratory and clinical skill applications. Furthermore, training environments and application demonstrations are mostly structured for right-handed students, which may cause left-handed students to experience more difficulties in technical applications.

Table 4.

Comparison of the characteristics of the participating students in terms of hand(s) used during episiotomy practices

Hand(s) used	Yes		No		X 2	p
	Having difficulty while performing episiotomy in the laboratory
Right handed	18	3.9	438	96.1	124.93*	0.000
Left handed	33	71.7	13	28.3
Ambidextrous	3	10.4	13	89.6
	Having difficulty while performing episiotomy in the clinical setting
Right handed	10	9.3	97	90.7	46.92*	0.000
Left handed	20	76.9	6	23.1
Ambidextrous	1	22.5	4	77.5
	Having difficulty while performing episiotomy repair in the laboratory
Right handed	29	5.6	492	94.4	101.82*	0.000
Left handed	33	63.5	19	36.5
Ambidextrous	3	11.0	15	89.0
	Having difficulty while performing episiotomy repair in the clinical setting
Right handed	27	9.7	252	90.3	86.21	0.000
Left handed	32	76.2	10	23.8
Ambidextrous	5	19.2	7	80.8

*Fisher’s exact test

According to the results of the EHPI, there were statistically significant differences (p < .001) between hand-dominance groups in terms of difficulties they had during episiotomy incision and episiotomy repair in both laboratory and clinical settings. The rate of facing difficulties was higher in the left-handed participants than it was in the other groups (Table 5).

Table 5.

Comparison of the participating students’ characteristics regarding episiotomy practices and handedness based on the results of the EHPI

Hand(s) used	Yes		No		X 2	p
	Having difficulty while performing episiotomy in the laboratory
Right handed	17	4.0	413	96.0	163.33	0.000
Left handed	26	10.4	12	89.6
Ambidextrous	11	22.0	39	78.0
	Having difficulty while performing episiotomy in the clinical setting
Right handed	11	22.9	91	79.1	50.66*	0.000
Left handed	18	90.0	2	10.0
Ambidextrous	2	12.5	14	87.5
	Having difficulty while performing episiotomy repair in the laboratory
Right handed	25	5.1	464	94.9	142.48	0.000
Left handed	27	62.8	16	37.2
Ambidextrous	13	22.0	46	78.0
	Having difficulty while performing episiotomy repair in the clinical setting
Right handed	25	9.6	235	90.4	98.14	0.000
Left handed	27	79.4	7	20.6
Ambidextrous	12	30.8	27	69.2

* Fisher’s Exact Test

The binary logistic regression analysis performed to determine the variables predicting left hand use demonstrated that the model was statistically significant (χ²(3) = 44.442, p<.001). The explanatory power of the model was 59.9% according to the Nagelkerke R² value, and the correct classification rate was 93.8%.

Having difficulty due to the hand used when an episiotomy is performed in clinical practice (OR = 27.460, 95% CI: 1.546–487.643, p=.024) and having difficulty due to the hand used during episiotomy repair in laboratory practice (OR = 6.629, 95% CI: 1.068–41.164, p=.042) were determined as significant predictors of left hand use. Difficulty due to the hand used during episiotomy repair in clinical practice was not significant (p=.963) (Table 6).

Table 6.

Logistic regression analysis of predictors of left-hand use during episiotomy-related practices

Predictors	B	SE	Wald χ²	p	OR	95% CI for OR
Difficulty due to the hand used while episiotomy is performed in clinical practice	3.313	1.468	5.094	0.024	27.460	1.546–487.643
Difficulty due to the hand used during episiotomy repair training in laboratory practice	1.892	0.932	4.122	0.042	6.629	1.068–41.164
Difficulty due to the hand used while episiotomy is repaired in clinical practice	-0.074	1.616	0.002	0.963	0.928	0.039–22.053

Model fit: χ²(3) = 44.442, p <.001; -2 Log likelihood = 44.053; Cox & Snell R² = 0.325; Nagelkerke R² = 0.599; overall classification accuracy = 93.8% 

Note. Dependent variable: left-hand use; coded as no = 0 and yes = 1, OR: odds ratio; CI: confidence interval; SE: standard error

Discussion

The results of the present study suggest that handedness may be associated with technical difficulties experienced during episiotomy training. The rate of the left-handed midwifery students who had difficulty performing episiotomy incision and episiotomy repair procedures was ≈ 70% in the laboratory and ≈ 75% in the clinic, while this rate was < 10% in right-handed students. These results demonstrate that left-handed students should be provided with equipment appropriate for their use and that hand-sensitive teaching strategies should be urgently integrated into the curriculum.

According to the results obtained from the EHPI, of the participating students, 82.4% were right-handed, 7% were left-handed, and 10.6% were ambidextrous [4, 30].

The rate of left-handedness and ambidexterity is reported as 10–15% and approximately 1%, respectively in general population [5, 30]. The 7% left-handedness rate in the present study was slightly below expectations, and the 10.6% ambidextrousness rate was above that reported in the literature. This result may be related to the adaptation strategies developed by the participants to use their non-dominant hands more actively during psychomotor skills training conducted in educational environments mostly designed for right-handed individuals. It is also thought that factors such as the scoring of threshold values and classification methods may also have led to the high rate of ambidextrousness.

The analysis of the participating students’ episiotomy practices revealed that they performed episiotomy and episiotomy repair by 49.5% and 33.6% more in the laboratory setting than they did in the clinical setting. Similarly, Duman (2024) reported that rates of performing episiotomy and episiotomy repair were higher in the laboratory than they were in the clinical setting [31]. This difference probably stems from the fact that laboratory conditions enable students to perform practices repeatedly. However, factors such as patient safety concerns, time constraints, and the presence of other healthcare professionals (medical residents, newly appointed midwives, etc.) in the clinic affect their practices adversely.

The rates of encouraging left-handed students to use their left hands actively in the laboratory and clinical setting are 37.5% and 31.3%, respectively, which suggests that left-handed students are not adequately supported to gain psychomotor skills. In a study conducted with left-handed surgeons, only 3% of left-handed surgeons received handedness-specific training during medical training, while 10% participated in programs supporting left-handed residents during residency training [32]. In a study conducted in India in which the challenges of being left-handed during Ear, Nose, and Throat (ENT) residency training were investigated, 50% of the left-handed participants reported that they were aware of the existence of surgical instruments for left-handed surgeons, but that none of them had an opportunity to access these instruments during their training [33]. In another study conducted in India, 94.4% of the residents reported that they received no training on left-handedness and frequently attempted to switch to their non-dominant hand, which made them feel disadvantaged [34]. In other studies in the literature, participants reported that they had virtually no access to surgical instruments designed for left-handed people in the educational or clinical settings [35, 36].

Inadequate encouragement of left hand use by the instructor limits the development of psychomotor skills in left-handed students, and thus has the potential to affect their learning process adversely. On the other hand, surgical instruments used and the instructor’s teaching method are mostly tailored to the needs of right-handed students, which may cause left-handed students to experience additional challenges in acquiring clinical competence. These difficulties may also negatively affect left-handed students’ performance in midwifery practices such as episiotomy requiring high levels of fine motor skills. According to Fitts and Posner’s Skill Acquisition Model, psychomotor skills develop within a learning process consisting of cognitive, associative, and autonomous stages [22]. Inadequate support for hand dominance during training is thought to affect students’ adaptation to clinical practices and their acquisition of technical skills adversely.

In a training program designed to enhance laparoscopy competence of left-handed pediatric residents, approaches for right-handed residents were rearranged according to the needs of left-handed residents. In the same training program, appropriate positioning of a patient and the provision of appropriate equipment ensured safe and effective procedures [37]. In a study in which the basic suturing skills of medical and nursing students were compared in terms of their being right- and left-handed, instructors reported that they had difficulties teaching left-handed students how to manage and grip instruments [38]. This suggests that dominant handedness-related differences are not adequately taken into account in both laboratory and clinical training environments, and that a right-handed teaching approach is adopted, which may unknowingly create a “right-handed pressure” on left-handed students. Similarly, the results of the present study demonstrated that using materials and improving learning environment settings in accordance with midwifery students’ handedness could reduce left-handed students’ difficulties in performing episiotomy practice and increase their performance and confidence.

Of the left-handed participating students, 71.7% had difficulties in laboratory practice, and 76.9% had difficulties in clinical practice. The higher rate of having difficulty in performing and repairing episiotomy in the clinical setting in the participants specified as left-handed according to the EHPI indicates that the scale can be used to distinguish respondents according to their dominant hand profile. The research indicated that determining the dominant hand by using a measuring tool, rather than asking, “Which hand do you use?” produced a more significant result.

In the present study, the left-handed participating students had a statistically significant difficulty in performing episiotomy and episiotomy repairs than did right-handed or ambidextrous students (p <.05). Similarly, Chapman (2009) noted that designing educational materials and surgical instruments for right-handedness created challenges for left-handed midwifery students [23]. In Pasinlioğlu’s (2003) study conducted in Turkey, it was also highlighted that success rates of left-handed students in practical and theory exams varied, and emphasized the importance of supporting handedness [24]. Power and Quilter (2016) also demonstrated that left-handed midwives’ not being allowed to use their left hands during the training process negatively affected the development of their psychomotor skills [25].

The binary logistic regression analysis performed in the present study demonstrated that the difficulty experienced due to the hand used, especially during episiotomy performed in clinical practice and episiotomy repair performed in a laboratory setting, is a significant predictor of left-hand use.

This result indicates that the left-hand dominant participants not only subjectively report more difficulties, but that these difficulties are also an important variable affecting their clinical and laboratory skill performances.

Especially in interventional skills such as episiotomy, training materials and demonstrations are mostly structured for right-handed individuals, which can adversely affect the psychomotor skill development of left-handed students [5, 21, 23].

As indicated in the literature, left-handed healthcare professionals experience difficulties in accessing appropriate equipment in their training processes, that they are often encouraged to adapt to right-hand techniques, which adversely affects their learning process [32–35]. On the other hand, it has been demonstrated that individualized instruction approaches and ergonomically designed training environments support the psychomotor skill development of left-handed students and improve their technical proficiency [6, 37, 38].

These results suggest that integrating hand preference-sensitive training strategies into the midwifery curricula can positively contribute not only to students’ professional competence but also to patient safety.

Strengths andlimitations of the study

Since the present study is one of the first studies in which the effect of hand preference on episiotomy and episiotomy repair skills in midwifery students was investigated, it can be considered significant. The study was conducted with a large sample group studying at different universities in Turkey increases the diversity of the results. Hand preference was assessed not only through self-report but also with a standardized measurement tool, and related variables was analyzed using logistic regression analysis are among the strengths of the study. It is believed that the results would contribute to the development of educational approaches in midwifery that take individual differences into account and pay attention to hand preference.

However, it has some limitations. Its cross-sectional design limits the establishment of causal relationships between the variables. Since the data collected was based on the participants’ self-reports, this may lead to bias due to perceived differences. In addition, the data was collected online via Google Forms, which may have created potential self-selection bias and digital access bias. Episiotomy skills were evaluated not through objective performance assessments, but through the participants’ perceived difficulty experiences. The study was conducted in different universities; thus, there may be differences in laboratory facilities and clinical practice experiences. Nevertheless, despite all these limitations, it is thought that the study would provide guidance for future research and trainings on hand-preference-sensitive midwifery education.

Conclusion

Episiotomy is the process of incising and repairing the vagina, which is crucial for women’s health and sexual life. Although training on this procedure, which is extremely important in its meaning and effect, seems less important in surgical terms, it requires great care and attention. The results of the present study revealed that left-handed midwifery students experienced a greater number of difficulties in performing episiotomy and repairing episiotomy than did their right-handed peers. It is important to enrich the curriculum with left-handed modules, to adapt physical conditions and equipment to facilitate left-handedness, to establish mentoring programs to maintain left-handed practice, and to raise awareness of this issue. Thus, implementing protocols that encourage left-handedness both in the laboratory and at the patient’s bedside not only will enhance left-handed students’ technical skills and professional confidence, but also will maximize patient safety.

Abbreviations

ICM

The International Confederation of Midwives

EHPI

Edinburgh Hand Preference Inventory

Author contributions

Conceptualization: [ND, AH], Methodology: [ND, AH, REG], Data collection: [ND, AH], Analysis and interpretation of data: [AH], Supervision: [AH, REG], Writing - original draft: [ND, AH, REG]. All authors read and approved the final manuscript.

Funding

None.

Data availability

The data sets used and/or analyzed during the current study can be obtained from the first author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study approved by the Ege University Scientific Research and Publication Ethics Committee (Approval No:13/10–172, Date; January 02, 2023), was conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from the students who agreed to participate in the study via Google Forms.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.